Provider Demographics
NPI:1790561777
Name:VANDE STOUWE, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:VANDE STOUWE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:537 MARCELLUS RD
Mailing Address - Street 2:
Mailing Address - City:WILLISTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11596-2117
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:165 ROWLAND WAY STE 208
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-5055
Practice Address - Country:US
Practice Address - Phone:415-697-8659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-05
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program